WPR23LA017

NTSB accident investigation · Cessna 177RG · Mesa, AZ · October 18, 2022

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
October 18, 2022, 07:40 local (14:40 UTC)
Place
Mesa, AZ · water canal
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N747MLCessna 177RG
Defining event
Approach-VFR pattern final: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Lycoming Engines, FAA
FAA report
20221018020669A
Case key
106158

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The failure of maintenance personnel to properly secure the fuel supply line to the fuel flow divider, which resulted in a fuel leak, fuel exhaustion, and a total loss of engine power.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fuel systemAircraft › Aircraft systems · Not serviced/maintainedCessna 177RG: 3 casesAll aircraft: 181 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 177RG: 3 casesAll aircraft: 371 casesProbable cause
Oversight: oversight of maintenanceOrganizational issues › Support/oversight/monitoring · Maintenance providerCessna 177RG: 1 caseAll aircraft: 28 cases
Fluids: fuelAircraft › Fluids/misc hardware · Fluid levelCessna 177RG: 10 casesAll aircraft: 1,695 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot conducted an hour-long local flight to break in the newly-installed engine, and was returning to the airport for landing when the engine lost all power. After a failed attempt to restart the engine, the pilot initiated a forced landing into a water canal. The airplane impacted a berm and came to rest in the canal, resulting in substantial damage to the left wing and engine mount. About one cup of fuel was recovered from each fuel tank during recovery from the accident site. Examination of the engine revealed that the fuel line from the fuel injection servo to the flow divider, which connected at the baffle union fitting on the aft side of the firewall, leaked when the engine-driven fuel pump actuated during the manual rotation of the propeller. The B-nut fitting could be tightened a half revolution until it seated onto the fitting by hand. There was no physical damage to the fitting, nor any accident-related impact damage within the surrounding area of the fitting. Review of the task cards for the engine installation provided by the repair station indicated that the installation was completed and signed off by both a technician and inspector. Based on the available information, it is likely that the B-nut was not properly torqued onto the baffle union fitting and that, during the accident flight, the B-nut loosened, resulting in a fuel leak, fuel exhaustion, and a total loss of engine power.

Factual narrative

On October 18, 2022, about 0740 Pacific daylight time, a Cessna 177RG, N747ML, was substantially damaged when it was involved in an accident near Mesa, Arizona. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that Falcon Aviation Services, based out of Falcon Field Airport (FFZ), Mesa, Arizona, reinstalled the overhauled engine and signed off the engine logbook entry on October 12, 2022. After multiple ground runs, the pilot completed an uneventful post-overhaul flight. The pilot reported that he departed on the accident flight about 0624 with 28 gallons of fuel onboard and maneuvered north of FFZ, where he flew about one hour orbiting about 4,000 ft above the ground at 65% to 75% engine power. The pilot returned to FFZ and was turning the airplane from base to final for runway 04R when the engine lost total power. The pilot attempted to restart the engine but was unsuccessful, and he conducted a forced landing into a water canal. The airplane impacted a berm and came to rest in the canal, resulting in substantial damage to the left wing, fuselage, and engine mount. (See figure 1.) During the recovery of the airplane, about one cup of fuel was recovered from each fuel tank. Figure 1. Google map view of wreckage location in relation to FFZ Runway 04R, with embedded picture of accident airplane in water canal. Postaccident examination of the airframe and engine revealed that the fuel supply line from the fuel injection servo to the fuel flow divider, which attached to the baffle union fitting, exhibited a surging fuel leak when the propeller was manually rotated. Fuel continued to surge from the fuel line fitting as the engine-driven fuel pump actuated with the continuous manual rotation of the propeller. It was determined that the fuel line B-nut (figure 2) was not secured and was able to be turned ½ revolution to “finger tight.” The fuel pump, fuel flow divider, and each corresponding fuel line was secured to its respective mounting pad or fuel system component. Figure 2. View of fuel supply line from fuel servo with overlayed close-up view of baffle union fitting connection (photo courtesy of engine manufacturer) According to the repair station, there were two primary installers of the accident engine, a technician and an inspector. The recovered task card for the engine installation revealed that the fuel system tasks, including a fuel leak check, were completed and signed off by both the technician and the inspector; however, it could not be determined which individual secured the fuel line to the baffle union fitting.

Aircraft

Registration
N747ML
Reported as
Cessna 177RG
Category
Airplane
Serial number
177RG0719
Built
1975
Airframe hours
3,849.3
Engine
Lycoming IO-360-A1B6D, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Restricted (Special); Standard, Normal
Last inspection
Annual · October 11, 2022 · 9 hours before
Destination
Same as departure
Airport
FFZ · Falcon Fld, runway 04, 5,100 × 100 ft, asphalt
Equipment
Data recorder, Auto-pilot, ADS-B, Onboard weather, Electronic primary flight display, Electronic flight bag or handheld device

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
75
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
BasicMed, With waivers/limitations
Last flight review
August 26, 2022
Seat
Left
Restraint
4-point
Flight hours
1,402.6 total · 1,187 in this make and model · 1,321.4 as pilot in command · 13.5 in the last 90 days · 10.3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
40° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 48 °F
Altimeter
30.08 inHg
Observed at
KFFZ, 1 nm away
METAR
KFFZ 181454Z 04009KT 10SM CLR 23/09 A3008 RMK AO2 SLP165 T02280094 53020 $

Docket · 12

The files NTSB released with the investigation on October 23, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 33.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.